Peds Shock

Table Of Contents
1 Cardiogenic Shock
2 Distributive Shock
3 Hypovolemic Shock
4 Obstructive Shock
5 Septic Shock
6 Case Study
6.1 Case 1
6.2 Case 2
6.3 Case 3
6.4 Case 4

Cardiogenic Shock

  • Etiology:
    • Deficiencies or impairment contractility
  • Presentation:
    • Cold shock
    • diminished peripheral perfusion
    • Mottled appearance
    • cold skin
    • narrow pulse pressure
    • decreased pulses
    • prolonged capillary refill
    • elevated pulmonary vascular pressures and venous pressures
    • hepatomegaly
  • Diagnosis:
    • a differential gradient can indicate impairment in cardiovascular function
    • assessment of urine output
  • Management:
    • Early recognition
      • Identify and treat compensated shock before it becomes uncompensated
    • 1st line therapy is inotropic agents:
      • dopamine
      • dobutamine
      • low dose epinephrine
    • Agent to afterload reduce the patient and to lower the systemic vascular resistance
      • milrinone (an inodilator)
      • lusitropic agents

Distributive Shock

  • Etiology:
    • Low systemic vascular resistance
    • effective circulating volume is maldistributed in the vascular space
  • Presentation:
    • Warm shock
    • bounding pulses
    • capillary refill will be brisk
    • wide pulse pressure (wide differential between systolic and diastolic pressures)
  • Management:
    • Vasopressor options:
      • high dose dopamine
      • high dose epinephrine
      • norepinephrine
      • phenylephrine (Neo-synephrine)
      • vasopressin

Hypovolemic Shock

  • Etiology:
    • Deficiencies in preload
  • Presentation:
    • History of volume loss
      • GI losses
      • hemorrhage and bleeding
    • Dry mucous membranes
    • Oliguria
    • Low CVP (central venous pressure)
  • Management:
    • Fluid resuscitation

Obstructive Shock

  • Etiology:
    • obstruction to blood flow
    • due to pulmonary embolism or cardiac tamponade

Septic Shock

  • Etiology:
    • 60% of patients:
      • cardiac index is reduced
      • systemic vascular resistance is high
    • 20-25% of patients:
      • high cardiac index
      • low systemic vascular resistance
    • 20% of patients:
      • reduced cardiac output
      • normal systemic vascular resistance

Case Study

Case 1
  • Presentation:
    • 1 Yo patient
    • Dilated cardiomyopathy
    • HR: 190 beats/minute, sinus tachycardia
    • CVP (central venous pressure): 20 mmHg
    • BP: 60/30 mmHg
    • Lactate is increasing
    • Mixed venous saturation from superior vena cava is 55%
    • Capillary refill > 5 seconds
  • Assessment:
    • Very high heart rate
      • indicative of compensated shock
    • High central venous pressure
      • indicative of an adequate vascular volume
      • but may reflect a significant cardiogenic failure
    • Low blood pressure
    • Patient is in cold shock
      • high systemic vascular resistance
      • afterload is high
    • Evidence of evolving shock 
      • lactic acidosis
      • low SVO2 state
  • Management:
    • Next appropriate management:
      • Inotropic agent with epinephrine
  • NOT appropriate: 
    • NOT Inodilator bolus with milrinone
      • bc concern for hypotension
      • reconsider with a higher blood pressure possibly add later
    • NOT Vasopressor (phenylephrine or vasopressin)
      • bc high SVRI (systemic vascular resistance index)
    • NOT Fluid bolus
      • bc given a central venous pressure of 20 mmHg the addition of an inotrope is a higher priority
      • this case is more of a cardiogenic failure
    • NOT Beta-blocker (Esmolol) to slow heart rate
      • bc it takes away the compensatory mechanism that the patient is using to augment oxygen delivery
      • impairment of cardiovascular function 
Case 2
  • Presentation:
    • 1 Yo patient
    • Dilated cardiomyopathy
    • HR: 190 beats/minute, sinus tachycardia
    • CVP (central venous pressure): 5 mmHg
    • BP: 60/30 mmHg
    • Lactate is increasing
    • Mixed venous saturation from superior vena cava is 55%
    • Capillary refill > 5 seconds
  • Management:
    • Initial step:
      • Fluid bolus
        • bc to view the amount of fluid responsiveness before inotropic agent
Case 3
  • Presentation:
    • 1 Yo patient
    • Dilated cardiomyopathy
    • HR: 190 beats/minute, sinus tachycardia
    • CVP (central venous pressure): 20 mmHg
    • BP: 110/90 mmHg
    • Lactate is increasing
    • Mixed venous saturation from superior vena cava is 55%
    • Capillary refill > 5 seconds
  • Management:
    • 1st choice:
      • Inodilator bolus with milrinone
        • inodilator and vasopressin (dilating) agent 
Case 4
  • Presentation:
    • 1 Yo patient
    • Hyperdynamic Septic Shock
    • HR: 190 beats/minute, sinus tachycardia
    • CVP (central venous pressure): 5 mmHg
    • BP: 60/30 mmHg
    • Lactate is increasing
    • Mixed venous saturation from superior vena cava is 55%
    • Capillary refill: 1 second
  • Management:
    • Vasopressor (Norepinephrine or vasopressin)
      • bc warm shock needing augment the systemic vascular resistance